acute epidural hematoma
Introduction
Introduction to acute epidural hematoma The epidural hematoma is a hematoma located between the inner plate of the skull and the dura mater. It is very common in the superficial hemisphere. Most of them are single-shot, and many are rare, but they can be combined with other types of hematoma to form a complex hematoma. Among them, epidural hematoma with epidural hematoma and hemorrhage in the hemorrhage site are more common, and intracerebral hematoma is rare. Epidural hematoma can be seen in any age patient, and is more common in young adults aged 15 to 40 years. Children have shallower intracranial vascular sulcus and tight adhesion between skull and meninges, less chance of injury to meningeal artery and meninges, and epidural hematoma is rare. basic knowledge The proportion of illness: 0.0035% Susceptible people: more common in young adults aged 15 to 40 Mode of infection: non-infectious Complications: swelling, edema, upper gastrointestinal bleeding, malnutrition, hemorrhoids
Cause
Acute epidural hematoma etiology
(1) Causes of the disease
The common cause of acute epidural hematoma is the tearing of the middle meningeal artery or its branches caused by skull fracture, forming a hematoma between the inner plate of the skull and the dura mater. Typical acute epidural hematoma is common in patients with craniocerebral fractures in young adults. It is most common in the front and front of the forehead.
(two) pathogenesis
The middle meningeal artery enters the cranium through the sinus of the middle cranial fossa and travels along the middle meningeal sulcus. It is divided into two parts at the wing point. The skull is thinner at the wing point. The middle meningeal artery and its branches can be fractured. Tear, the hemorrhage of the main hemorrhage is mainly in the forehead. The blood hematomas formed in the front are mostly located in the forehead or frontal part. The post-expendation blood hematoma is mostly located in the dome or ankle. The meningeal artery is fierce and the hematoma can be rapidly increased. Cerebral palsy within a few hours, particularly acute epidural hematoma seen in the bleeding here, forehead trauma or anterior cranial fossa fracture, can damage the anterior ethmoid artery and its branches (anterior meningeal artery), in the forehead or amount The epidural hematoma is formed at the bottom. Here, the hematoma formation is slow and rare in clinical practice. It is easy to miss diagnosis. Sometimes the fracture and the meningeal vein accompanying the middle meningeal artery are slow, and the hematoma is mostly subacute or chronic. It is rare in clinical practice. The sinus and transverse sinus may cause a parasitic sinus hematoma due to a fracture of the corresponding site, a hematoma of the posterior cranial fossa or an epidural hematoma that straddles the sinus, a vein of the stenosis or a blood vessel that penetrates the skull is caused by a fracture. It can form a hematoma in the epidural space, which can be met clinically, but the hematoma is slower than that caused by sinus hemorrhage. Sometimes there is no fracture after head trauma, but external force can separate the dura mater from the skull, resulting in tiny blood vessels. Tearing to form an epidural hematoma, mostly located at the point of traumatic injury, the formation is slow and the hematoma is small, the acute epidural hematoma is less in the occipital region, because the dura mater and the occipital bone are attached tightly, and often venous Hemorrhage, according to research, hematoma should be stripped from the skull, at least 35g of force, but sometimes, due to the fracture line through the superior sagittal sinus or transverse sinus, can also cause a huge epidural hematoma riding across the sinus The continuous expansion of this type of hematoma, mostly caused by the re-bleeding of the dura mater and the intraosseous plate, is caused by new rebleeding, not just by venous pressure.
The size of the hematoma is closely related to the severity of the disease. The heavier and heavier, but the bleeding rate is more prominent. The small and urgent hematoma often has symptoms of brain compression in the early stage, while the slow hemorrhage occurs in days or even weeks. Shows an increase in intracranial pressure, an acute hematoma located in the convex surface of the hemisphere, often pushing the brain tissue inward and downward, so that the hippocampus and the hook back inside the temporal lobe protrude below the edge of the cerebellum, compressing the cerebral peduncle, oculomotor nerve, brain The posterior artery affects the reflux of the pons vein and the superior sinus of the sinus. It is called the epidural hemorrhage of the cerebellum. It is a long-term epidural hematoma. It usually grows in 6 to 9 days and grows into the fibroblasts by the dura mater. There is a thin layer of granules wrapped and adhered to the dura mater and skull. The small hematoma can be completely mechanized, and the large hematoma is cystic and the brown bloody liquid is stored.
Prevention
Acute epidural hematoma prevention
The disease is a traumatic disease, no preventive measures, pay attention to safety, and avoid trauma.
Complication
Acute epidural hematoma complications Complications swelling edema upper gastrointestinal bleeding malnutrition acne
If surgery is performed, in addition to the common complications of common brain injury and craniotomy, special attention should be paid to:
1. Postoperative observation should be closely observed, and recurrent hematoma and delayed hematoma should be treated promptly.
2. Secondary brain swelling and cerebral edema should be properly controlled.
3. Severe patients may have upper gastrointestinal bleeding, and should be prevented early in the operation.
4. Long-term coma patients are prone to pulmonary infection, water and electrolyte balance disorder, hypothalamic dysfunction, malnutrition, hemorrhoids, etc., while strengthening nursing measures, should be dealt with in a timely manner.
5. Follow-up survey should be conducted within 1 to 3 months after discharge to understand the surgical results and possible intracranial complications.
Symptom
Acute epidural hematoma symptoms Common symptoms Nausea disturbances Intracranial pressure increase Hypertension Reduced severe headache Cerebral palsy Ataxia Reflex hyperthyroidism Cardiac arrest disappears
The clinical manifestations of epidural hematoma may vary depending on the bleeding rate, hematoma location and age, but from the clinical characteristics, there are still certain regularities and commonalities, namely coma-awake-re-coma. Take the case of an acute epidural hematoma on the screen as an example, which is summarized as follows:
1. Disorder of consciousness: Due to the different degree of primary brain injury, there are three different situations in the consciousness of this type of patient: 1 primary brain injury is mild, no primary coma after injury, until the formation of intracranial hematoma, Progressive intracranial hypertension and disturbance of consciousness begin to appear, and such patients are easily missed. 2 The primary brain injury was slightly heavier. After the injury, he was once unconscious. Then he was completely awake or consciously improved, but he soon fell into a coma. Such patients are so-called typical cases and easy to diagnose. 3 primary brain injury is serious, persistent coma after injury, and progressive deepening performance, the signs of intracranial hematoma often masked by primary brain contusion or brain stem injury, more easily misdiagnosed.
2. Increased intracranial pressure: With increased intracranial pressure, patients often have headaches, increased vomiting, turbulence and typical changes in the four curves, namely Cushing's reaction, increased blood pressure, increased pulse pressure difference, increased body temperature, heart rate And compensatory reactions such as slow breathing, when the exhaustion, blood pressure drops, pulse is weak and respiratory depression.
3. Signs of the nervous system: simple epidural hematoma, less signs of nerve damage in the early stage, only when the hematoma forms the oppressed brain function area, there is a corresponding positive sign, if the patient immediately appears facial paralysis, hemiplegia or aphasia When symptoms and signs are present, they should be attributed to primary brain injury. When the hematoma continues to increase, causing the sacral leaf to return to the sputum, the patient will not only have deepened conscious disturbances, but also have vital signs, and there will be typical signs such as dilated pupils on the affected side and hemiplegia of the contralateral limbs. Occasionally, because the hematoma develops rapidly, causing the early brain stem to be distorted, displaced and embedded on the contralateral cerebellar stenosis, it should cause atypical signs: the contralateral pupil dilated, contralateral hemiplegia; Large, ipsilateral hemiplegia; or contralateral pupil dilated, ipsilateral hemiplegia. Positioning should be performed immediately with the aid of an auxiliary inspection.
Examine
Examination of acute epidural hematoma
1. Skull X-ray film: The incidence of skull fracture is high, about 95% shows skull fracture.
2. CT scan: the performance of the double convex lens density increased, the boundary is sharp, the bone window position can show the skull fracture of the hematoma, the ipsilateral ventricular system is compressed, and the midline structure is shifted to the opposite side.
3. MRI: It is not used for acute phase examination. The morphology is similar to that of CT. It is fusiform and sharply bordered. The T1-weighted image is an equal signal. The inner edge of the dura can be seen as a low signal, and the T2-weighted image is a low signal.
Diagnosis
Diagnosis and differentiation of acute extradural hematoma
Diagnosis can be based on medical history, clinical symptoms, and laboratory tests.
When patients have increased headache, vomiting, restlessness, increased blood pressure, increased pulse pressure difference, and/or new signs, they should be highly suspected of intracranial hematoma, and timely necessary imaging examinations, including X-ray skull radiographs, Type A ultrasound, cerebral angiography or CT scan.
